HomeMy Public PortalAbout9085 WOOLLEY ST_Miscellaneous__ WCOKERS'COMPENSATION DECLARATION 76M444
CE 875 (11.84) MISCELLANEOUS APPLICATION {�
I hereby a certificate
/ ate I have a certificate of consent tself COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION I�
insure, or a certificirate of Workers'Compensation Insurance,e,or
a certified copy thereof(Sec.3800,Lab.Q.
PolicyNo.-Company BUILDING n
p y FOR APPLICANT TO FI LL IN C��1t
ADDRESS
Certified copy is hereby furnished. BUILDING C� ST'
ADDRESS O `JOOLL LOCALITY
Certified copy is filed with the county building inspection LOCALITY T�y�pGE C Sj+/7�p NEAREST
department. CROSS s1.
Date Applicant NEAREST // / DIS l�T O. G UP TYPE PROCESSED BY
CROSS ST. I�/ /i% '�f may' CONST;
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL d**�� (J �/
COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK—T3J62: MAP HIGHWAY STATE MAJOR SECOND LOCAL
NO. (CIRCLE)
NO. OF HLDGS.
(This section need not be completed if the work involved TRACT /oZ�0 NOW ON LOT A;;R-
ONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) 6Q0/� USE of
SIZE OF LOT �` 3�J(•/ EXISTING BID sC'�.E / �'
I certify that in the performance of the work for which this •� o
permit is issued,I shall not employ any person in any manner owNER-;eE5e �7 fx}.54
so as to become subject to the Workers' Compensation Laws. MAIL J f- OCCUPANCY GROUP o
Date Applicant ADDRESS 6 V�OOQGL� S7"
TEL W 6� OCCUPANT LOAD °-
NOTICE TO APPLICANT: If,after making this Certificate of CITY py�' `/ NO. �e a / /
Exemption, you should become subject to the Workers' gppL CATION FOR EXIT HARDWARE: _
Compensation provisions of the Labor Code,you must forth-
wlth comply with such provisions oI this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl.
deemed revoked. � Panic Devices
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING
_ SPACES REq'D D PROVIDED O
License Number Lic. Class Ah
LIMITED TIME USE
Contractor Date DATE DATE
�
I am exempt from the licensing requirements as I am a FROM: TO:
licensed architect or a registered professional. engineer 111E of NO. OF INSPECTOR'S
acting in my professional capacity (Section 7051, Bus- EXISTING BLDGDO STORIES u E
iness and Professions Code). FINAL APPROVAL
PRESENT USE OF BUILDING �� D
Lic.or Reg.No. Date E •�/
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ZI D o 8 4 5 0
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's o 0 0 8 0.5 0 5
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO. PARKING Z
I, as owner of the property, will do the work and the SPACES PROVIDED +
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING '
I hereby affirm that there is a construction lending agency 64AM69F S'EZvji(/ ICOO ��
for the performance of the work for which this permit is '
issued(Sec.3097,Civ.Q.
Lender's Name
PROPOSED MAX. OCC.
Lender's Address ±'
I certify that I have read this application and state that the PERMIT FEE :��� , •
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction, sg7
and hereby authorize representatives of this County to enter TOTAI.FEE
on the above-me tioro property for inspection purposes.
B d-' SEE REVERSE FOR EXPLANATORY LANGUAGE
7
S' natur Permittee Date